Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wisconsin Dells Health Services during CMS and state inspections, most recent first.
A facility failed to maintain a sanitary food service environment when a microwave and refrigerator in the memory care unit kitchenette were observed dirty, with food splatters, crumbs, and spills inside. Staff gave conflicting answers about who was responsible for cleaning the equipment, and the NHA acknowledged miscommunication between departments.
A resident with an activated POA had a CPR/DNR Preference Form indicating DNR status, but the form was not signed by the POA. The NHA stated the POA had called into the care conference and gave verbal agreement, but acknowledged the form should have had the POA’s signature.
A resident with Parkinson's disease, muscle wasting, and dementia was care planned for bilateral side rails during cares only, with documentation that the rails must be put back down when cares were not being performed. Surveyors observed the resident in bed with side rails raised and no staff present on two occasions, and CNA and RN staff confirmed the rails should only be up during cares and should have been lowered afterward.
Surveyors found that the facility lacked an effective pest control program, as evidenced by mouse droppings in the dry storage room and multiple exterior doors with large gaps and broken frames that allowed pest entry into the kitchen area. The Dietary Manager reported the issue to the Maintenance Director, but pest control services were not promptly provided, and invoices showed only limited pest control actions. Both the Maintenance Director and Administrator confirmed the need for door repairs to prevent further pest access.
The facility failed to maintain a sanitary environment for food storage and preparation, affecting all residents. Surveyors found frozen condensation in the freezer contaminating unsealed food, and a mixer stored unclean. An open supplement was undated on a medication cart, violating facility policies.
Multiple breaches in infection control were observed, including improper hand hygiene by an LPN during wound care and medication administration, incomplete monitoring of water heater temperatures as part of the water management program, an outdated pneumococcal vaccine policy, and delayed identification of a norovirus outbreak. The facility's infection preventionist and maintenance director confirmed these deficiencies during interviews.
The facility failed to maintain a safe environment for two residents, one with severe cognitive impairment who experienced falls without timely intervention updates, and another with a motorized wheelchair improperly charged in the hallway. Staff were unaware of proper protocols, indicating a lack of training and policy implementation.
The facility failed to provide adequate dialysis care for two residents, as their care plans lacked emergency procedures for dialysis complications. Staff interviews revealed a lack of knowledge on handling emergencies, with some indicating they would leave residents to find a nurse. Additionally, emergency kits were missing from residents' rooms, and the facility's policy did not include guidance on emergency interventions.
A resident receiving nutrition and medication via G-tube did not have proper tube placement verification prior to feeding, as required by facility policy. Nursing staff demonstrated inconsistent methods for checking placement, and a nurse was observed administering tube feeding without verifying placement immediately beforehand.
A resident receiving oxygen therapy for multiple respiratory and cardiac conditions did not have their oxygen tubing changed and labeled weekly as required by physician orders and facility protocol. Staff interviews and observations confirmed the absence of date labeling and documentation, and the facility's policy lacked clear instructions on tubing changes.
Surveyors found two open and used tubes of medicated ointment on a medication cart without resident names. An LPN confirmed the tubes were not labeled and could not identify the intended residents. The DON confirmed that ointment tubes should be labeled with a resident's name.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to ensure staff followed the care plan and that fall interventions were functioning. The resident, requiring assistance for transfers and ambulation, was observed moving independently, and staff were unaware of the need for assistance. The care plan was inconsistent with the resident's MDS, and interventions like a bathroom door alarm were not working. Staff interviews revealed a lack of awareness and understanding of the resident's care needs.
A resident's morning medications were administered late, and the facility failed to promptly address the grievance reported by the resident's APOA. The issue was not logged in the grievance log, and the NHA and DON were unaware of the complaint until the surveyor's visit. The RN who received the complaint did not take immediate action to resolve the issue.
The facility failed to ensure timely administration of medications for two residents, resulting in multiple medication timing errors. Resident 1 did not receive morning medications until noon, and Resident 3's medications scheduled for 7:30 AM and 8:00 AM were administered between 11:22 AM and 12:41 PM. The DON confirmed that medications should be administered within one hour before or after the scheduled time, but this was not adhered to.
A resident received Metoprolol Succinate ER late on two consecutive days, resulting in four significant medication timing errors. The doses were not administered within the acceptable one-hour window before or after the scheduled time, nor were they evenly spaced by 12 hours as required. The DON confirmed the importance of timely medication administration and proper documentation.
DA J failed to properly test the final rinse chemical level of a dish machine using the correct Ecolab test strips, and two unlabeled drink items were found in the dietary reach-in refrigerator. The District Manager confirmed the correct testing procedure and the need for proper labeling and storage of food items to avoid contamination.
The facility failed to maintain an effective infection prevention and control program, impacting 48 residents and specifically two residents on Enhanced Barrier Precautions. Staff were not up to date with N95 fit testing, and proper PPE protocols were not followed during high-contact care activities for two residents.
A facility failed to ensure proper catheter care and hand hygiene for a resident with an indwelling urinary catheter. A CNA reused a washcloth during the care process, did not perform hand hygiene between steps, and placed dirty washcloths directly on the bedside table without disinfecting it afterward. The infection preventionist confirmed these actions were against the facility's policies.
A resident with severe cognitive impairment and a history of PTSD did not have a person-centered care plan addressing PTSD triggers and interventions. Despite receiving medications for PTSD, the care plan lacked specific strategies, and staff were unclear about the resident's triggers and appropriate interventions.
Unclean kitchenette equipment in memory care unit
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During observation of the memory care unit kitchenette, the microwave was found with food splatters on the inside and the refrigerator had crumbs and food spilled inside. The report states this condition had the potential to affect all 9 residents who reside on the memory care unit. Interviews showed staff were unclear about responsibility for cleaning the kitchenette equipment. Housekeeper F said she did not know who was responsible for cleaning the refrigerator and stated housekeeping was responsible for cleaning the microwave. CNA G thought housekeeping was responsible for cleaning the kitchenette. The Dietary Manager said he would assume the staff working in memory care were responsible for cleaning the refrigerator and microwave, then later stated the CNA's would be responsible because they were logging temperatures. The NHA stated kitchen staff were responsible for keeping the refrigerator and microwave clean and acknowledged there was miscommunication between departments.
Advance Directive Form Lacked POA Signature
Penalty
Summary
The facility failed to ensure that one resident’s advance directive was signed by the resident’s representative. R28 was admitted to the facility and had an activated power of attorney in place. R28’s CPR/DNR Preference Form indicated that R28 wished to be DNR, but the document was dated and did not have the Power of Attorney’s signature. During an interview, the Nursing Home Administrator stated the facility did not have a signed form from the POA because the POA called into R28’s care conference meeting, the form was completed, and verbal agreement was obtained; the NHA also stated the form should have had the POA’s signature.
Side rails left raised outside of cares
Penalty
Summary
Proper use of bed rails was not ensured for one resident, R5, who was care planned for side rails up with cares only. R5 was admitted on 12/10/25 and had diagnoses including Parkinson's disease, muscle wasting and atrophy, and dementia. The record showed a physician order for bilateral side rails while in bed, per resident request, to assist with independent mobility and repositioning, with the instruction that they were for cares only. The resident's risk vs benefit documentation stated that bedside rails are not standard practice and may carry risks including entrapment, injury, or increased fall risk if used improperly, and the side rail assessment stated the rails could be used during cares only and must be put back down when cares were not being performed. Surveyors observed R5 lying in bed with side rails raised and no staff present on two occasions. On 4/29/26 at 9:01 AM, R5 was observed with the right upper side rail up and no staff in the room. CNA D later stated the rails should have only been up while cares were occurring and observed that they were not down. On 4/30/26 at 7:10 AM, R5 was again observed with side rails up on both sides and no staff present. RN C stated the rails were only up for cares and should not have been left up after cares. The DON also stated the rails were for cares only and needed to be down prior to staff leaving the room.
Deficient Pest Control Due to Damaged Exterior Doors
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent pests and rodents from entering the building, specifically through damaged exterior doors leading into the kitchen and dry storage areas. During an inspection, surveyors observed two small black droppings in the dry storage room, identified as likely mouse droppings. Multiple exterior doors, including the food service delivery door and doors near the dry storage area, were found to have significant gaps and broken frames, allowing visible light and potential access for pests and rodents. The door to the dry storage room was also not sealed at the bottom, further compromising pest control measures. These observations were confirmed by the Dietary Manager and Corporate Dietician during the inspection. Interviews revealed that the Dietary Manager had reported the presence of mouse droppings to the Maintenance Director the previous week, who indicated that pest control services would be scheduled, but the pest control provider did not arrive as planned. Review of pest control invoices showed monthly treatments for exterior bait stations and specific treatment for ants in one resident room, but did not indicate comprehensive action for the kitchen or dry storage areas. The Maintenance Director and Administrator both confirmed the existence of gaps and the need for repairs to the identified doors to prevent pest entry.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food storage, preparation, and distribution, potentially affecting all 44 residents. During an inspection, surveyors observed frozen condensation on the ceiling of the facility's walk-in freezer, with pieces of frozen condensation falling onto and inside boxes of unsealed food, posing a risk of contamination. The Dietary Manager acknowledged the issue and indicated that the condensation builds up and freezes, requiring regular scraping. Additionally, the facility's policy on food storage was not adhered to, as evidenced by water-damaged boxes and unsealed food exposed to ice. Further observations revealed that a mixer was stored covered but unclean, with dried food particles present, contrary to the facility's policy requiring all food contact equipment to be cleaned and sanitized after use. Additionally, an open and used box of Imperial Med Plus 2.0 Vanilla Supplement was found on a medication cart without a date indicating when it should be used by, which was confirmed by an LPN. These deficiencies highlight lapses in maintaining cleanliness and proper labeling, which are essential for ensuring food safety and preventing contamination.
Deficient Infection Control Practices and Program Implementation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple breaches in hand hygiene during wound care and medication administration, incomplete water heater temperature monitoring, outdated vaccination policies, and delayed outbreak identification. During wound care for a resident with a wound, an LPN removed gloves and applied new gloves without performing hand hygiene, despite facility policy and CDC guidelines requiring hand hygiene between glove changes. The same LPN also failed to perform hand hygiene before donning gloves and after removing gloves during medication administration, including after performing a blood glucose test and before administering subcutaneous injections. Contaminated gloves were used to touch resident items, and hand hygiene was not performed at required intervals, contrary to facility policy and best practices. The facility's water management program was also deficient, as only one of three water heaters had its temperature routinely monitored and documented. The maintenance director confirmed that temperature logs were only kept for the laundry water heater, not for the two water heaters serving resident rooms. This is inconsistent with the facility's own water management plan and CDC guidance, which require monitoring to prevent the growth of Legionella bacteria. The director of nursing/infection preventionist acknowledged that all water heater temperatures should be documented as part of the water management plan. Additionally, the facility's policy and procedure for pneumococcal vaccination was not up to date with current CDC recommendations, and the infection preventionist was unaware of recent changes in vaccine guidance. The facility also failed to promptly identify the start of a norovirus outbreak, calling the outbreak a day after the threshold for an outbreak had been met according to both CDC and state guidelines. The director of nursing/infection preventionist agreed that the outbreak should have been recognized earlier based on the number of affected residents and staff.
Deficiencies in Fall Prevention and Safety Protocols
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R25 and R7. R25, who has severe cognitive impairment and is at risk for falls, experienced two falls without appropriate interventions being implemented. After the first fall, the intervention was to have physical therapy assess the walker and educate on brake usage, but this was not effectively communicated or implemented. Following the second fall, the care plan was not updated with new interventions until after the surveyor's observation, indicating a lack of timely response to the resident's fall risk. R7, who relies on a motorized wheelchair for mobility, had their wheelchair charging in the hallway, which is not compliant with safety protocols requiring charging behind a fire-safe door. Staff members, including a CNA and an LPN, were unaware of the proper storage and charging procedures for motorized wheelchairs, and the Director of Nursing was unsure about the policy. This lack of awareness and training among staff contributed to the unsafe practice observed by the surveyor. The facility's policies on fall prevention and comprehensive care planning were not effectively followed, as evidenced by the lack of updated interventions in R25's care plan and the improper charging of R7's wheelchair. The Director of Nursing acknowledged that the care plan should have been updated with new interventions, and the Nursing Home Administrator confirmed the requirement for charging wheelchairs behind a fire-safe door, highlighting a gap in policy implementation and staff education.
Deficiency in Dialysis Emergency Procedures
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care consistent with professional standards and their care plans. Two residents, both diagnosed with end-stage renal disease and dependent on dialysis, were found to have care plans that did not include emergency procedures for complications related to their dialysis ports. The facility's Hemodialysis policy also lacked specific interventions for emergencies, which contributed to the deficiency. For one resident, the care plan included monitoring for signs of infection and abnormalities at the dialysis site but did not specify actions for emergencies. Interviews with staff revealed a lack of knowledge on how to handle bleeding from a dialysis port, with some staff indicating they would leave the resident to find a nurse, contrary to the expectation of staying with the resident and using the call light. Additionally, an emergency kit that was supposed to be available in the resident's room was missing. Similarly, the second resident's care plan did not address emergency procedures for dialysis complications. Staff interviews showed a similar lack of preparedness, with staff indicating they would leave the resident to alert a nurse. An emergency kit was also missing from this resident's room, and the facility's policy did not provide guidance on emergency interventions. The Nursing Home Administrator later acknowledged the absence of emergency kits and the need for care plans and policies to include emergency procedures.
Failure to Properly Verify G-Tube Placement Prior to Feeding
Penalty
Summary
The facility failed to ensure proper verification of G-tube placement prior to administering tube feeding and medications for one resident. According to the facility's policy, staff are required to verify the placement of gastrostomy tubes before beginning a feeding, flushing the tube, or administering medications. This includes checking that the enteral retention device is properly positioned, measuring and recording the length of the tube, and confirming placement before each use. However, during observation, a registered nurse did not verify the G-tube placement prior to administering tube feeding, instead relying on a previous check and using a stethoscope to listen while flushing the tube with water. Interviews with nursing staff revealed inconsistent practices for verifying G-tube placement, with some staff indicating they use air instillation and listen for bubbles, while others check for residuals by aspirating stomach contents. The Director of Nursing also described various methods, including instilling air, observing the site, and assessing for resident discomfort. Despite these described methods, the facility was not following current standards of practice for verifying G-tube placement, as evidenced by the observed failure to check placement immediately prior to tube feeding for the resident in question.
Failure to Ensure Timely and Documented Oxygen Tubing Changes
Penalty
Summary
A deficiency was identified when a resident with a history of pneumonia, chronic obstructive pulmonary disease, and acute on chronic systolic congestive heart failure was not provided respiratory care consistent with professional standards. The resident was receiving oxygen therapy via nasal cannula, with physician orders specifying oxygen administration and a weekly change of oxygen equipment. However, observations on multiple occasions revealed that the oxygen tubing was not labeled with the date of change, and there was no documentation to confirm that the tubing had been changed weekly as ordered. Interviews with facility staff, including an LPN, CNA, and the Director of Nursing/Infection Preventionist, confirmed that the protocol required weekly changes of oxygen tubing, labeling with the date, and documentation on the MAR/TAR. Despite these protocols, the staff were unable to verify when the tubing was last changed due to the absence of labeling and documentation. The facility's provided policy on oxygen concentrators did not include instructions on when to change oxygen tubing, further contributing to the lack of compliance with the resident's care orders.
Unlabeled Medicated Ointments Found on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled in accordance with professional standards. Specifically, on the 400 hall medication cart, there were two open and used tubes of medicated ointment—muscle rub and hydrocortisone acetate 1% cream—without any resident names on the labels. When questioned, an LPN confirmed that the tubes were open and used but could not identify which resident they belonged to, as the tubes were not labeled. The Director of Nursing/Infection Preventionist confirmed that ointment tubes are expected to be labeled with a resident's name, and that labeling is necessary to determine the usability of opened products.
Failure to Implement and Monitor Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that staff were following the plan of care for a resident with severe cognitive impairment, leading to multiple falls. The resident, who requires assistance for transfers and ambulation, was observed transferring and ambulating independently. Staff were not aware of the resident's need for assistance, and the care plan was not consistent with the resident's most recent Minimum Data Set (MDS). Additionally, the resident's fall interventions, such as a bathroom door alarm, were not functioning properly, and staff were unaware of these deficiencies. The resident's care plan included various interventions to minimize fall risks, such as anti-skid strips, a bathroom door alarm, and reminders to use a walker. However, these interventions were not effectively implemented or monitored. The resident experienced multiple falls, some of which resulted in injuries, such as a dislocated shoulder. Despite these incidents, the facility did not complete a root cause analysis or update the care plan to reflect changes in the resident's physical abilities or to address the resident's cognitive limitations. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan and fall interventions. Staff relied on verbal reports and Kardex entries, which were not up-to-date or consistent with the resident's needs. The facility's failure to ensure that staff were informed and that interventions were functioning contributed to the resident's continued risk of falls and injury.
Failure to Promptly Address Resident Grievance on Late Medication Administration
Penalty
Summary
The facility did not make prompt efforts to resolve a grievance regarding a resident's late medication administration. The resident, who has dementia and other medical conditions, did not receive their morning medications until noon on a specific date. The resident's activated power of attorney (APOA) reported the issue to the facility the following day. However, the facility failed to address the grievance promptly, as evidenced by the fact that the concern was not logged in the facility's grievance log, and the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unaware of the issue until the surveyor's inquiry. The Registered Nurse (RN) who received the complaint from the APOA did not take immediate action to investigate or resolve the issue. The RN only informed the NHA via email, which was not reviewed until the surveyor's visit. The resident and their family were not informed about the reasons for the late medication administration, whether the primary physician was notified, or if the noon medications were given on time. This lack of prompt action and communication led to the deficiency noted in the report.
Medication Timing Errors for Two Residents
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of each resident, resulting in medication timing errors for two out of three sampled residents. On 5/19/24, Resident 1 did not receive their morning medications until noon, and Resident 3 did not receive their scheduled 7:30 AM and 8:00 AM medications on time, leading to 20 medication timing errors. The facility's policy states that medications should be administered within 60 minutes of the scheduled time, but this was not adhered to in these cases. Resident 1, who has diagnoses including dementia, weakness, obesity, fibromyalgia, depression, and anxiety, did not receive their morning medications until noon on 5/19/24. The delay was brought to the facility's attention by the resident's daughter, who called on 5/20/24 to voice her concern. The Registered Nurse (RN) on duty confirmed that all of Resident 1's morning medications were administered late, but the primary physician was not notified. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were also unaware of the late administration until informed by the surveyor. Resident 3's medications were also administered late on 5/18/24 and 5/19/24. The Medication Administration Record (MAR) and Medication Admin Audit Report documented that multiple medications scheduled for 7:30 AM and 8:00 AM were administered between 11:22 AM and 12:41 PM. The DON confirmed that medications should be administered within one hour before or after the scheduled time and that any medication errors should be reported to the nurse on call, physician, and power of attorney. However, the DON was unaware of the late administrations and no medication errors were noted for Resident 3.
Significant Medication Timing Errors
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors. The resident, who had a physician's order for Metoprolol Succinate ER to be administered at 7:30 AM and 7:30 PM, received the medication late on two consecutive days. Specifically, on 5/18, the morning dose was administered at 11:24 AM and the evening dose at 7:17 PM. On 5/19, the morning dose was administered at 12:40 PM and the evening dose at 6:54 PM. This resulted in four significant medication timing errors, as the doses were not administered within the acceptable one-hour window before or after the scheduled time, nor were they evenly spaced by 12 hours as required. The Director of Nursing (DON) confirmed that medications should be administered per physician orders and within the specified time frame. The DON was unaware of the late administration of the medication and stated that there were no documented medication errors for the resident. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and documenting the administration immediately. The surveyor's attempt to speak with the RN who administered the medications late was unsuccessful, and the DON acknowledged the importance of timely medication administration and proper documentation.
Improper Dish Machine Testing and Unlabeled Food Items in Refrigerator
Penalty
Summary
Dietary Aide (DA) J failed to properly test the final rinse chemical level of a low-temperature dish machine, which is essential for ensuring that dishware is sanitized correctly. During an observation, DA J used the wrong test strips (Hydrion test strips meant for quaternary chemical) instead of the appropriate Ecolab test strips for chlorine. This incorrect testing method resulted in a test strip that showed no chemical presence, indicating that the dishware might not have been properly sanitized. The District Manager confirmed that the dish machine should be tested with Ecolab test strips, and the Ecolab Representative corroborated this information, emphasizing that the correct test strips were not used by DA J. Additionally, two drink items, a partially full glass bottle of Starbucks Frappuccino and a full bottle of Dasani water, were found unlabeled in the dietary reach-in refrigerator. Cook I was unable to identify whether these items belonged to dietary staff or residents. The District Manager stated that staff food items should not be stored in the same refrigerator as food meant for resident consumption to avoid contamination. If the drinks were for resident consumption, they should have been labeled with the resident's name and stored in a designated refrigerator for resident items.
Infection Control Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, affecting the census of 48 residents and specifically impacting two residents observed on Enhanced Barrier Precautions (EBP) protocol. The facility failed to ensure all staff were fit-tested annually for N95 mask use, as required by OSHA regulations. During a COVID outbreak, it was discovered that 42 out of 80 staff members were not up to date with their fit testing, including 27 from the Nursing Department. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the lapse in fit testing compliance. Additionally, Enhanced Barrier Precautions were not appropriately implemented and maintained for two residents. One resident, admitted with a bacterial infection, required substantial assistance with toileting and transfers. Despite an order for enhanced precautions, a CNA was observed assisting the resident without wearing gloves. Another resident, with a diagnosis of lymphocytosis and a PICC line, required moderate assistance with toileting and transfers. A CNA was observed placing the resident's wash basin without wearing a gown or gloves, contrary to the facility's policy. Interviews with the CNA and Infection Control Preventionist confirmed the failure to adhere to proper PPE protocols during high-contact care activities.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility did not ensure a resident with a catheter received appropriate treatment and services to prevent urinary tract infections. During an observation, a CNA performed catheter care on a resident without following proper hand hygiene protocols. The CNA did not perform hand hygiene between cleansing the catheter tubing and peri area and drying. Additionally, the CNA reused a washcloth after cleansing, placing it back in the soapy water basin and using it again on the resident's peri area. The CNA also placed dirty washcloths directly on the bedside table and did not disinfect the table after use, which is against the facility's policies for hand hygiene and catheter care. The resident involved had a diagnosis of neuromuscular dysfunction of the bladder and benign prostatic hyperplasia with lower urinary tract symptoms. The resident's care plan included the use of an indwelling urinary catheter due to urinary retention and lower urinary tract symptoms. The CNA's actions were observed to be inconsistent with the facility's policies, which require proper hand hygiene, the use of clean washcloths for each step of the catheter care process, and the placement of a barrier under supplies on the bedside table. Interviews with the CNA and the infection preventionist confirmed that the CNA did not follow the proper procedures for hand hygiene and catheter care. The CNA admitted to not using a clean washcloth for rinsing and not placing a barrier under the supplies. The infection preventionist also confirmed that the bedside table should have been disinfected after removing the used washcloths and towel. These actions and inactions led to the deficiency in providing appropriate catheter care to prevent urinary tract infections for the resident.
Failure to Provide Appropriate PTSD Care
Penalty
Summary
The facility did not ensure that a resident diagnosed with PTSD received appropriate treatment and services to address the condition. The resident, who had severe cognitive impairment and a history of PTSD, did not have a person-centered care plan that specified triggers, symptoms to monitor, or interventions to use. The care plan only included general interventions for behavioral disturbances related to other diagnoses but did not specifically address PTSD. Interviews with staff revealed that they were aware of some triggers for the resident's PTSD, such as loud noises and certain individuals, but these were not documented in the care plan. The resident was admitted with multiple diagnoses, including PTSD, unspecified dementia with agitation, and mood disorder. Despite the diagnosis of PTSD being listed in the resident's medical records and the resident receiving medications for PTSD, the care plan did not reflect individualized interventions for managing PTSD. Staff interviews indicated a lack of clarity and consistency in identifying and documenting the resident's PTSD triggers and appropriate interventions. The social worker and nursing staff were aware of the PTSD diagnosis but had not developed a specific care plan to address it. Additionally, there was confusion regarding the resident's PTSD diagnosis. A physician's note suggested considering PTSD, but it was not confirmed as an actual diagnosis. Despite this, the resident continued to receive medications for PTSD. The Director of Nursing acknowledged that the medical record should accurately reflect diagnoses and that a care plan for PTSD should be in place. However, the care plan remained incomplete, lacking specific strategies to manage the resident's PTSD effectively.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Wisconsin Dells
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Jefferson Meadows Llc | 9.7 mi | ★★★★★ | 0 | 0 |
| Ridgeview Terrace Long Term Care | 12.5 mi | ★★★★★ | 0 | 0 |
| Sauk Co Health Care Center | 14.7 mi | ★★★★★ | 5 | 0 |
| Fair View Nursing And Rehabilitation Center | 19.4 mi | ★★★★★ | 10 | 0 |
| Maplewood Of Sauk Prairie | 23.6 mi | ★★★★★ | 14 | 0 |
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